Based on on interview, observation, and record review, conducted during a site visit on 07/01/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 2, 3, and 4). Findings include, but are not limited to:

In an interview with Staff 1 (RN) on 07/01/24, s/he stated the facility used a "staffing matrix" to determine the staffing needs for any given day.

A review of the facility's ABST showed a need for 52.53 care staff hours.

An observation of the staff present for day shift on 07/01/24 showed 45.5 care staff hours were scheduled for that day.

A review of the facility's ABST revealed Resident 4, who admitted on 06/25/24, was not entered into the tool as of 07/01/24.

In an interview, Staff 1 stated the facility's expectation for answering calls was within 10 minutes.

A review of call light logs for Resident 3, dated 06/24/24 to 07/01/24, revealed 13 instances where wait times were greater than 15 minutes.

A review of call light logs for Resident 2, dated 06/24/24 to 07/01/24, revealed seven instances where wait times were greater than 15 minutes.

In an electronic communication recieved on 07/08/24, Staff 3 (Administrator) stated the facility's posted staffing plan reflected the minimum staffing required based on census.

The findings were reviewed with and acknowledged by Staff 1 on 07/01/24.

The facility failed to fully implement and update an Acuity Based Staffing Tool.